When the COVID-19 vaccine rollout began, there seemed no good answers for what to do with leftover doses. Vaccinators were punished for giving shots in violation of priority lists, while fearful clinics were condemned for throwing doses away.
“Early on, the question was, ‘Is the absolute red line that you don’t throw a dose away? Or is the red line that you don’t give it to the wrong person?'” said Dr. Matthew Zahn, medical director of the division of epidemiology for Orange County in California.
Federal guidelines existed but weren’t widely emphasized. The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices issued guidance urging “a flexible approach” to the vaccine, especially when it was in danger of going unused.
Former Surgeon General Jerome Adams tweeted out if it was a case of choosing between wasting vaccine or moving down the priority groups, the correct action was to put vaccine in arms.
States however, didn’t consistently embrace or communicate that to the vaccinators in their area, said Dr. Kelly Moore, deputy director of the non-profit Immunization Action Coalition.
In some cases, administrators seemed to worry too much about optics and what might seem like inequities or favoritism when vaccine was in extremely short supply, said Zahn.
Ten weeks into the U.S. vaccination effort, most hospitals, clinics and vaccination centers now have protocols and systems in place to make sure every last dose gets used.
“The No. 1 rule is vaccine cannot go to waste,” said Zahn, a fellow with the Infectious Diseases Society of America. “Have a reasonable plan to try in good faith to reach the most eligible people, but don’t waste vaccine!”
‘Somewhere in there, the vaccine got overpromised’: How the COVID-19 vaccination process turned chaotic and confusing
Some have embraced that approach from the beginning.
“We’ve always taken the stance that every dose is a life, so we’ve never thrown a dose away,” said Alan Harris, the Emergency Manager of Seminole County in Florida.
Just because it’s the right thing to do doesn’t mean it easy. Making sure every last dose is used requires legwork, said Harris.
Every Tuesday and Friday his staff call the 100 or so nursing homes and assisted living facilities in the county to find out if they have new residents or staff who need to be vaccinated.
They compile a list, and then, if there are doses left over from a vaccination clinic, staff members start making calls.
“When they get that phone call, it’s delight on the other side of the phone,” Harris said.
Vaccine delivery controversies
The approachis a stark contrast to instances where vaccinators have been censured for giving leftover doses before they went bad to whoever they could find.
One notorious case involved Dr. Hasan Gokal in Houston. He was accused of stealing a vial of vaccine from the Harris County Public Health District on Dec. 29 because he gave unused doses that would have gone to waste to friends and family.
He filed paperwork accounting for what he had done and was promptly fired and charged with theft. The charges were later dismissed.
New York Gov. Andrew Cuomo initially threatened health care providers with a $1 million fine and loss of their licenses if they vaccinated someone who was not eligible. That was walked back following reports of clinics throwing away doses rather than giving them to people who might not fit the eligibility profile.
Massachusetts is up front about “vaccine wastage,” as it’s called. It makes a chart available online showing tossed COVID-19 vaccine, which in almost all cases was discarded because of storage or delivery problems that let doses get too warm for too long.
The state’s vaccine allocation guidance specifically calls for all vaccine to beused, even if it means moving down the eligibility list.
“In the rare instance where you have COVID-19 vaccine that will expire and you have no one in the current priority groups to be vaccinated, you can use your clinical judgment to administer the vaccine to a person in another priority group,” it says.
While the issue gets a lot of attention, overall vaccine waste appears to be very low, said Dr. Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials. While there’s no actual data, anecdotally he’snot heard much concern about it.
“Most clinical systems are experienced in doing this, they have standards of practice in place to organize how much vaccine they’re going to need for a given clinic,” he said.
That’s the case in Nashville, Tennessee, where Siloam Health has worked to make sure no doses go unused.
“We try to schedule vaccination patients in groups of 10, because there are 10 doses in a vial” of the Moderna vaccine, said Dr. Morgan Wills, CEO of the low-income health network.
Vaccination clinics are scheduled in the morning, so if there’s any extra vaccine because someone didn’t show up it can be offered to afternoon clinic patients.
They’ve also created a list of all the network’s patients by age so they can call and ask if someone can come in right away if there are extras.
“We didn’t have somebody dedicated to that beforehand, so we had to allocate a staffer,” Willis said. “Thankfully, we have a very detail-oriented member of our team who’s lending a hand.”
Requirements boost challenge
COVID-19 vaccine is problematic not only because it’s in short supply but because of its exacting storage requirements.
The Pfizer vaccine is shipped frozen in vials that contain up to six doses. To be used, the vial must first be thawed and then mixed with a saline solution. Once mixed, it can be held at room temperature, but if it’s not used within six hours it must be discarded.
The Moderna vaccine also is shipped frozen, in 10-dose vials. It is brought to room temperature, the rubber cap is punctured and vaccine is drawn into a syringe for injection. Once the top has been punctured, the rest of the vial must be used within six hours.
At many COVID-19 vaccination sites, a pharmacist fills syringes with vaccine, which are then taken to the health care professionals doing the vaccination.
“As we get closer to the end of the day, we do fewer syringes to decrease the possibility we’ll have any leftover. At the very last half hour we only fill them as people come in,” said Seminole County’s Harris.
The county never has more than five doses of Pfizer (sometimes it’s possible to get six doses out of a vial) or nine doses of Moderna vaccine at the end of a clinic. Generally, it’s no more than two or three.
Whatever is left is put in small battery-powered refrigerators used to store insulin, about the size of two stacked boxes of spaghetti.These are driven by health care providers to the assisted living facility where someone is waiting.
The important message for vaccinators is that vaccine is precious and should never go to waste, said Dr. Amesh Adalja, a senior scholar, Johns Hopkins Center for Health Security.
That’s especially important in inclement weather when people might not make it to their vaccination appointments
“Maybe you order a pizza and you vaccinate the pizza delivery person,” he said. “You need to have backup plan after backup plan.”